Post COVID Thyroiditis as Documented on Tc-99m Pertechnetate Thyroid Scan

Aim/Introduction: The etiology of SAT (subacute thyroiditis) is presumed to be usually viral (most commonly associated viruses include enterovirus, coxsackievirus, mumps, measles, and adenovirus). In this pandemic era, prevalence of SAT associated with the COVID 19 seems to be increasing either during or after the course of disease, characterized by neck pain or discomfort, goiter and transient hyperthyroidism. However, this is usually missed due to the wide spectrum of COVID syndrome, and a simple thyroid scan can be instrumental in diagnosing related thyroiditis. Material(s) and Method(s): We report 3 (1 male, 2 females) cases of thyroiditis detected using Tc99m pertechnetate scan. Thyroid scan was done 20 minutes after injection of 5 milicuries (170 MBq) of Tc99m pertechnetate and planar images were acquired. Result(s): 3 (1 male, 2 females) cases of thyroiditis detected using Tc99m pertechnetate scan. Mean age was 36.3 years. Symptoms such as goiter (n=1), neck pain and tenderness (n=2), weakness and fatiguability (n=3), palpitations (n=2), heat intolerance (n=1), restlessness (n=2) were observed along with raised T3, T4 hormone levels and suppressed TSH, 3-4 months after COVID infection (mean duration 3.3 months). Other possible causes of thyroiditis and drug interference were ruled out. Thyroid scan images revealed faint or absent tracer uptake in thyroid gland. Conclusion(s): The affinity of SARS-Cov-2 to the thyroid gland has been presumed via the ACE2 receptors which are more prevalent in thyroid cells than lung cells. Inflammatory response and apoptosis is another proposed factor. Ultrasound will show a normal or enlarged thyroid but typically, diffusely, or focally hypoechogenic, and the color Doppler sonography will demonstrate low flow but thyroid scan is easier to perform, is less user dependent and carries more diagnostic value. COVID related thyroiditis can present months after infection and is a part of long COVID syndrome. Possibility of post immunization also exists. Thyroid scan can be widely used in these scenarios.

Humans and Nature: Conflict or Cooperation?

The present state of the world looks not very optimistic, particularly since the COVID-19 pandemic turned life upside down. It hit everybody by surprise, arriving at ‘the worst moment imaginable' (as one would say) when the Fridays For Future activists point to the dramatic situation of our environment – two global catastrophes at a time are a bit much. But the human society has to live with nature, and this cohabitation is not without problems. At the end of this book, we dare express a few general thoughts about the recent past and a potential future. © 2022, The Author(s), under exclusive license to Springer Nature Switzerland AG.

Comprehensive, longitudinal wastewater surveillance for SARS-CoV-2 across a university campus, demonstrates low levels of SARS-CoV-2 activity relative to the surrounding community

Background. Universities are interactive communities where frequent contacts between individuals occur, increasing the risk of outbreaks of COVID-19. We embarked upon a real-time wastewater (WW) monitoring program across the University of Calgary (UofC) campus measuring WW SARS-CoV-2 burden relative to levels of disease in the broader surrounding community. Figure 1 The colour scheme shows 6 sewer sub-catchments at the University of Calgary. Auto samplers were deployed at 4 sampling nodes within sub-catchments CR and YA (both residence halls), and UCE and UCS (catchments that include several campus buildings). Figure 2 Log10-transformed abundance (i.e., copies per mL) of nucleocapsid gene (i.e., N1) for SARS-CoV-2 for each sampling location during October 2021 - April 2022. Locations denoted by the same letters (A, B, or C) show no statistical difference (p > 0.05) according to the Wilcoxon rank-sum test. The WWTP sample corresponds to a catchment area covering most of Calgary including the university campus, for which sampling locations CR, UCE, UCS, and UCW are defined in Fig. 1. Methods. From October 2021 - April 2022, WW was collected thrice weekly across UofC campus through 4 individual sewer sampling nodes (Fig. 1) using autosamplers (C.E.C. Analytics, CA). Results from these 4 nodes were compared with community monitoring at Calgary's largest WW treatment plant (WWTP), which received WW from surrounding neighborhoods, and also from UofC. Nucleic acid was extracted from WW for RTqPCR quantification of the N1 nucleocapside gene from SARS-CoV-2 genomic RNA. Qualitative (positive samples defined if cycle threshold < 40) and quantitative statistical analyses were performed using R. Results. Levels of SARS-CoV-2 in WW were significantly lower at all campus monitoring sites relative to the WWTP (Wilcoxon rank-sum test p < 0.05;Fig. 2). The proportion of WW samples that were positive for SARS-CoV-2 was significantly higher for WWTP than at least two campus locations (p < 0.05 for Crowsnest Hall and UCE - University way and campus drive) according to Fischer's exact 2-sided test. The proportion of WW samples with positive WW signals were still higher for WWTP than the other two locations, but statistically not significant (p = 0.216). Among campus locations, the buildings in UCE catchment showed much lower N1 signals than other catchments, likely owing to buildings in this catchment primarily being administration and classroom environments, with lower human-to-human contact and less defecation compared to the other 3 catchments, which include residence hall, a dining area, and/or laboratory spaces. Conclusion. Our results show that SARS-CoV-2 RNA shedding in WW at the U of C is significantly lower than the city-wide signal associated with surrounding neighborhoods. Furthermore, we demonstrate that WW testing at well-defined nodes is a sampling strategy for potentially locating specific places where high transmission of infectious disease occurs.

Comparative performance of RTqPCR vs RTddPCR for the detection of SARS-CoV-2 in wastewater (WW) collected from a range of sites and scales across the sewer network of Calgary, Alberta

Background. We sought to compareWWSARS-CoV-2 RNA detection across a range of sites and scales using RTqPCR and RTddPCR. Figure. Methods. Composite-24hWW was collected from aWWtreatment plant (WTP;n=18), a neighborhood (Nb1;n=12) and three hospitals;H-1, H-2, and H-3 (3-sites;A-C)(n=84). RNA was extracted using the 4S-silica column method. RTqPCR (QuantStudio5, Thermo Fisher) and RTddPCR (C1000 Thermal Cycler and QX200 Droplet Reader, BioRad) quantified SARS-CoV-2 RNA nucleocapsid (N2, US CDC) and envelope (E Sarbeco, Corman et al 2020) in triplicate. Fisher's exact test was used to compare assay sensitivity. Correlations between modalities and RNA - clinically-confirmed COVID-19 cases (defined by postal code of primary residence using 5-day rolling average) was assessed using Persons correlation. Results. 114 samples were tested (02/23/2021-04/22/2021). SARS-CoV-2-N2 was identified in 90/114 (79%) by RTqPCR and 89/114 (78%) by ddPCR (p=1). SARS-CoV-2 E was found in 72/114 (63%) by RTqPCR and 90/114 (79%) by ddPCR, p=0.01. Correlations between modalities were strongest for N2 relative to E across all sites (see Table). N2 correlated with clinically diagnosed cases for both modalities greater at the level of the WTP (RTqPCR;r=0.8972, p< 0.0001and ddPCR;0.933, p< 0.0001) relative to neighborhood (RTqPCR;r=0.6, p=0.04 and ddPCR;0.60, p=0.04). E correlated to a lesser degree with cases at WTP (RTqPCR;r=0.65, p=0.0035 and ddPCR;0.88, p=< 0.001) and neighborhoods (RTqPCR;r=0.40, p=0.20 and ddPCR;r=0.43, p=0.16). Conclusion. SARS-CoV-2 detection of N2 was similar between RTqPCR and RTddPCR across a range of sites and scales in the sewershed, and this correlated best with clinical cases whereas E detection was superior with ddPCR.

Effect of High-Dose versus Standard-Dose Dexamethasone on Mortality Among Mechanically Ventilated COVID-19 Patients

Background. Anti-inflammatory agents like dexamethasone (DEX) have become a mainstay of treatment for COVID-19. Despite randomized trials demonstrating that a 6 mg daily dose of DEX improved patient outcomes in hospitalized COVID-19 patients receiving oxygen, clinicians often prescribe higher doses of corticosteroids without evidence to support this practice. The purpose of this study was to compare outcomes of ventilated COVID-19 patients who received standard dose (SD) versus high dose (HD) DEX. Methods. This was a multi-site, retrospective, observational study of ventilated COVID-19-positive patients who received at least three days of DEX between June 1, 2020 and January 31, 2022. Sample size was calculated based on a 3:1 high:standarddose prescribing pattern ratio. The primary outcome of this study was the association between mortality and SD (<6mg daily) versus HD ( >10mg daily) DEX in ventilated COVID-19 patients. Secondary outcomes included average blood glucose (BG), number of BG readings above 200, incidence of bacterial nosocomial infection, ventilatorfree days, length of stay (LOS) and ICU LOS. Results. Of 322 patients screened, 110 were excluded primarily for average daily DEX dose of > 6 to <= 10mg. Of the 212 included patients, 53 (25%) received SD DEX and 159 (75%) received HD DEX. Data demonstrate no significant effect of DEX dose on mortality, number of BG readings > 200, incidence of nosocomial infections, LOS, or ventilator-free days (p >0.05). After controlling for confounding factors no difference in mortality persisted (OR 1.45 95% CI 0.66- 3.20). Average daily BG and ICU LOS were significantly greater in the HD group compared to the SD group (p = 0.003, p = 0.019 respectively). Conclusion. There is no association betweenHDDEX and mortality among ventilated COVID-19 patients compared to SD DEX. Moreover, HD DEX is associated with detrimental effects such as prolonged ICU LOS and higher average daily BG. This study supports the use of SD DEX in ventilated COVID-19 patients.

Surveillance of SARS-CoV-2 variants of concern (VOC) in hospital wastewater (WW) and its correlation with hospitalized cases of COVID-19 and the occurrence of outbreaks

Background. WW surveillance enables real time monitoring of SARS-CoV-2 burden in defined sewer catchment areas. Here, we assessed the occurrence of total, Delta and Omicron SARS-CoV-2 RNA in sewage from three tertiary-care hospitals in Calgary, Canada. Methods. Nucleic acid was extracted from hospital (H) WW using the 4S-silica column method. H-1 and H-2 were assessed via a single autosampler whereas H-3 required three separate monitoring devices (a-c). SARS-CoV-2 RNA was quantified using two RT-qPCR approaches targeting the nucleocapsid gene;N1 and N200 assays, and the R203K/G204R and R203M mutations. Assays were positive if Cq< 40. Cross-correlation function analyses (CCF) was performed to determine the timelagged relationships betweenWWsignal and clinical cases. SARS-CoV-2 RNA abundance was compared to total hospitalized cases, nosocomial-acquired cases, and outbreaks. Statistical analyses were conducted using R. Results. Ninety-six percent (188/196) of WW samples collected between Aug/ 21-Jan/22 were positive for SARS-CoV-2. Omicron rapidly supplanted Delta by mid-December and this correlated with lack of Delta-associated H-transmissions during a period of frequent outbreaks. The CCF analysis showed a positive autocorrelation between the RNA concentration and total cases, where the most dominant cross correlations occurred between -3 and 0 lags (weeks) (Cross-correlation values: 0.75, 0.579, 0.608, 0.528 and 0.746 for H-1, H-2, H-3a, H-3b and H-3c;respectively). VOC-specific assessments showed this positive association only to hold true for Omicron across all hospitals (cross-correlation occurred at lags -2 and 0, CFF value range between 0.648 -0.984). We observed a significant difference in median copies/ ml SARS-CoV-2 N-1 between outbreak-free periods vs outbreaks for H-1 (46 [IQR: 11-150] vs 742 [IQR: 162-1176], P< 0.0001), H-2 (24 [IQR: 6-167] vs 214 [IQR: 57-560], P=0.009) and H-3c (2.32 [IQR: 0-19] vs 129 [IQR: 14-274], P=0.001). Conclusion. WWsurveillance is a powerful tool for early detection andmonitoring of circulating SARS-CoV-2VOCs.Total SARS-CoV-2 andVOC-specificWWsignal correlated with hospitalized prevalent cases of COVID-19 and outbreak occurrence.

Decreased mortality in coronavirus disease 2019 associated mucormycosis with aspirin use: a retrospective cohort study.

OBJECTIVE: Rhino-orbito-cerebral mucormycosis is a rapidly progressive disease with high mortality rates of about 60 per cent. The increasing incidence of rhino-orbito-cerebral mucormycosis in coronavirus disease 2019 patients in India and worldwide has become a matter of concern owing to the case fatality rate. This study explored the use of low dose aspirin in decreasing the mortality rate of coronavirus disease 2019 associated mucormycosis. METHOD: This was a retrospective observational study. Patients suffering from post-coronavirus disease 2019 mucormycosis were included in the study. Each patient was treated with surgical debridement and systemic amphotericin B. Low dose aspirin was added, and mortality rates were compared with the patients who did not receive aspirin. RESULTS: The demographic data and rhino-orbito-cerebral mucormycosis staging between the two groups were not significantly different. There was a statistically significant difference in mortality outcomes between the two groups (p = 0.029) and a 1.77 times higher risk of dying for patients not receiving aspirin. Kaplan-Meier survival indicated that patients receiving aspirin had better survival rates (p = 0.04). CONCLUSION: Low dose aspirin improves survival rates in coronavirus disease 2019 associated mucormycosis.

Perception of Students on Online Assessment: A Descriptive Study among Medical Undergraduates at Basic Sciences

Background Assessment drives learning. Student assessment cannot be neglected in the long ongoing online learning during COVID-19 pandemic to motivate and assess students’ learning. Hence Patan Academy of Health Sciences (PAHS) conducted online assessment to medical undergraduates amidst limitations. Objective To measure the perception of online assessment of students which will provide applicable insights for the further improvement. Method This is a single center, cross-sectional and descriptive study. A Google form containing a semi-structured questionnaire was sent to MBBS students of Basic Science at PAHS who attended online classes and online examination. The responses from close ended questions expressed in percentage and Chi-square test was used to find the association. Open ended questions were analyzed using Braun and Clarke’s thematic analysis. Result Of 118 students that responded, 75% passed the online examination. A majority of students (73%) stated that online exam motivated them in learning process and it could be a good alternative during pandemic time. However the most of students (56%) were unsatisfied with the modality of online assessment and reasons that they mentioned were technical problems (89%), inadequate online proctoring (77%), insufficient examination time (58%), lack of orientation to exam, lack of computer skills. Technical problem was worse in rural areas. Conclusion Even though online assessment motivated students’ learning during online classes, a large number of students were unsatisfied with assessment modality. © 2021, Kathmandu University. All rights reserved.

Evaluation of hydroxychloroquine-based combination therapies for the treatment of COVID-19

Background: During the early COVID-19 pandemic a large number of investigational agents were utilized due to lack of therapeutic options. We evaluate the utility of commonly-used investigational agents combined with hydroxychloroquine (HCQ). Methods: This multicenter observational cohort study included patients admitted with COVID-19 between March - May 2020 in Detroit, Michigan who received at least 2 doses of HCQ. Our primary outcome was the change in Sequential Organ Failure Assessment (SOFA) score from presentation to day 5 of HCQ therapy with a secondary outcome of in-hospital mortality. Data collected included demographics, Charlson Comorbidity index (CCI), daily SOFA score, laboratory data and COVID-directed therapies. Multiple linear regressions were performed to control for potential confounders between different therapies and change in SOFA score. Results: Three hundred thirty-five patients receiving HCQ were included. Patients were 62 ± 14.8 years of age, male (54%) and African-American (82%) with a mean CCI of 1.7 ± 1.9. In our cohort, 32% were admitted to the intensive care unit and 35% expired. Therapies received by more than 20% of patients in addition to HCQ included azithromycin (80%), zinc (76%) and vitamin D (29%). In our unadjusted analysis, a significant improvement in SOFA score was observed with zinc (0.76) while no significant change was observed with azithromycin (-0.46) or vitamin D (0.05). However, there was no significant change in SOFA score after adjusting for confounders for azithromycin, zinc and vitamin D. No difference in mortality was observed between the groups. Conclusion: Overall, no benefit in end-organ damage or mortality was observed with the addition of azithromycin, zinc or vitamin D to HCQ. Further studies are needed to confirm this observation.

Research Letters

We conducted this online survey to assess the parental perspectives on remote learning, the associated stress, and school reopening during the COVID-19 pandemic. Of 2694 responses, 2032 (75.4%) parents perceived remote learning to be stressful for the child and 1902 (70.6%) for the family. The mean (SD) duration of remote learning was 3.2 (2.1) hours/day and 5.3 (1.0) days/week. Parents from 1637 (61.7%) families reported headaches and eye strain in children. Starting regular school was not acceptable to 1946 (72.2%) parents.